2.0 Analysis 2.1 Problems Associated with the Use of Portable Very High Frequency Radiotelephones by Shore Staff - Impact on Safety As all communication is channelled through the LRO and as clearance procedures incorporate some safeguards, the need for communication between the ship's officers is reduced. The interference due to the high level of noise associated with vehicular traffic, the lack of formal procedures and the widespread use of non-standard terminology by terminal staff in relaying essential messages, all contributed to the problems associated with communication. This resulted in needless re-transmission of the same information and consequential high volume of correspondence. The observations made and the information obtained indicated that the terminal personnel did not always repeat back the complete message when acknowledging receipt of a communication. As such, when the ATA engaged the lone TO in a conversation to emphasize the need to maintain the ferry schedule, critical information respecting the diversion of vehicles to top up the load on the upper deck, which was missed by the TO, went unnoticed. The requirement to repeat back the complete message ensures that it has been received and fully understood by the addressee. Also, the LRO did not repeat the complete TO's clearance to that person to ensure accuracy. The cumulative effect of all of the above rendered communication unreliable and ineffective. Consequently, it precluded effective monitoring. The communication difficulties were not isolated to this occurrence and have been in existence for some time. While communication principles are outlined in a cursory manner in the company manual, only a few terminologies have been incorporated. The terminal staff, who was not appropriately certificated, did not follow the fundamental principles of communication which are essential for safe loading operations in an extremely busy environment. The need for clear, precise and decisive language, which is essential for safe marine operations, is well established and reflected in the Standard Marine Navigational Vocabulary established by IMO. This requirement is also emphasized in the company's policies. The vocabulary does not include terminology for loading/unloading operations or clearance procedures. Nonetheless, in the interest of safety, the philosophy and the underlying principles could be used and a set of terminology/expressions generated. 2.2 Hazard Associated with Stopping a Vehicle on Apron As the Ramp Operations Handbook makes no reference to the hazards associated with stopping a vehicle on the apron and because the apron is in a float mode during loading operations, the hazard associated with the loss of support of the vessel's deck, as in this instance, compromised vessel, passenger and crew safety. 2.3 Position of Upper Ramp - Conflicting Evidence The LDO reported that the upper ramp appeared to him to be off the upper deck and that he had associated this to shoehorning. In order for this to occur, given the distance between the fingers and the ship's bifold safety gate, vehicles must be outside the designated stowage area on the upper deck. This unprotected area, aft of the bifold gate, serves only as a landing area for the ramp, apron and vehicle transit. Upon completion of loading, the gate is wheeled across the entrance (photographs - Appendix B). This gate can be closed with the ramp and apron still on deck. About the time the vehicle fell in the water, the UDS threw a lifering into the water and closed this safety gate. This would indicate that no vehicle was overhanging the upper apron and that there was no impediment to raising the apron. This is further substantiated by the fact that the hydraulics were not engaged and that the apron was in the float mode. 2.4 Impact of Ferry Schedule on Safety Although the company maintains that it does not pressure employees to maintain ferry schedules, the practices or behaviour/conduct of the company or its agents, whether it is intentional or not, could readily be interpreted as pressure by the employees. This is reflected in the information contained in the Ramp Operations Handbook (see Section 1.13 for details). Because ferries transport large numbers of passengers and vehicles and operate on tight schedules that they are expected to meet, particularly during the busy summer season, ship and terminal staff alike constantly have to avoid delays, whenever possible. Once delayed, it would be difficult for a ferry to regain the schedule for the day. The difficulty in regaining the schedule is indicated by the fact that the ferry had departed four minutes behind schedule on her first trip and that she was nine minutes behind schedule when she was about to commence the second leg of her first round trip, despite a vehicular load of about 70 per cent. The preoccupation of the terminal and ship staff with maintaining the ferry schedule is reflected in the responses and/or actions taken by various members of the staff. While this factor did influence the decision making and work norms/practices of the employees, the extent to which it contributed to this occurrence cannot be established because of a number of variables. However, the inopportune timing of the conversation wherein the ATA emphasized to the TO the need to maintain ferry schedules resulted in the TO missing important loading information, i.e. vehicle diversion to the upper deck; and the fact that the UDO left the loading area before the vehicle loading had been completed because her presence on the bridge was essential for the vessel's departure, contributed to the ferry departing prematurely and compromised passenger/crew/vessel safety. 2.5 Crew Performance and Safety Generally, as the single upper ramp loading facility at Departure Bay results in the final vehicle being loaded on the upper deck, the completion of loading on the upper deck then triggers the clearance procedures. Thus, the LDO could have expected that the loading on the upper deck may not be complete, more so as the lower deck load was only about 70 per cent. But, as all clearances to the LDO are issued by the LRO and as all communication is handled through the LRO, the latter is expected to be knowledgeable about all phases of loading and is required to ensure that the upper ramp is clear before issuing clearance to the ferry. As the LDO surveyed the scene, he saw evidence that was consistent with the completion of loading: there were no more vehicles to board the lower deck; the foot passenger ramp was clear; and the time was right. If his assessment was that the vessel was clear, he could very easily rationalize that the upper ramp was not completely clear of the upper deck because of shoehorning. This would be consistent with his assessment and could have been more easily accepted, in the absence of compelling evidence to the contrary, than a realization that the upper ramp was not clear. Operating pressures such as on-time performance and cost savings can make employees more susceptible to such phenomena. 2.6 Safety Associated with Loading and Clearance Procedures The practice aboard this vessel permitted the UDO to proceed to the bridge before the loading was completed on the upper deck. Despite this, there was no exchange of information between the master and the UDO regarding the loading status of the upper deck, and the master relied solely on the clearance issued by the chief officer. Although there was no closed-circuit monitoring system for the upper deck, no procedure was in place for the upper deck personnel to notify either the LDO or the bridge to confirm completion of loading operations. Sole reliance was placed on the LRO's clearance to the chief officer in an extremely busy environment. 3.0 Conclusions The ferry was behind schedule and, once delayed, it is difficult to regain a schedule, placing operational pressures on the ship and terminal staff. The upper deck officer (UDO) left the loading deck before the loading was completed to expedite the ferry's departure. The assistant terminal agent (ATA) engaged the lone tower operator (TO) in a conversation at a crucial time in the loading process which resulted in valuable information respecting the loading operation being missed. The company-established procedures in the operations manual had been replaced with other accepted practices that compromised safety. The TO issued a conditional clearance. The lower ramp operator (LRO) did not repeat the complete TO's clearance back to ensure accuracy. The lower deck officer (LDO), without confirming that the upper deck had completed loading, assumed that the apron was clear of the upper deck and that the ferry was ready to sail. The closed-circuit monitoring system for the ferry did not include the upper deck area, and no procedure was in place for the upper deck personnel to notify either the LDO or the bridge to confirm completion of loading operations. Unsafe practices such as the issuing of conditional clearances were not identified during the safety audits conducted by the British Columbia Ferry Corporation (BCFC). There was no directive to prohibit vehicles from being stopped on the apron during the final stages of loading operations. The TO's workload and responsibilities were considerable. Vehicular noise and the use of informal procedures and non-standard vocabulary effectively diminished the quality of communication. There was no procedure in place to double-check the clearances. The LRO did not check to ensure that the upper ramp apron was clear of the ship. The LRO lifted the lower apron without authority from the LDO. The ferry sailed prematurely and the upper ramp lost support, tipping the van and its occupants into the water. During the rescue operation, difficulty was experienced in launching and rowing a lifeboat with a minimum emergency response crew.3.1Findings The ferry was behind schedule and, once delayed, it is difficult to regain a schedule, placing operational pressures on the ship and terminal staff. The upper deck officer (UDO) left the loading deck before the loading was completed to expedite the ferry's departure. The assistant terminal agent (ATA) engaged the lone tower operator (TO) in a conversation at a crucial time in the loading process which resulted in valuable information respecting the loading operation being missed. The company-established procedures in the operations manual had been replaced with other accepted practices that compromised safety. The TO issued a conditional clearance. The lower ramp operator (LRO) did not repeat the complete TO's clearance back to ensure accuracy. The lower deck officer (LDO), without confirming that the upper deck had completed loading, assumed that the apron was clear of the upper deck and that the ferry was ready to sail. The closed-circuit monitoring system for the ferry did not include the upper deck area, and no procedure was in place for the upper deck personnel to notify either the LDO or the bridge to confirm completion of loading operations. Unsafe practices such as the issuing of conditional clearances were not identified during the safety audits conducted by the British Columbia Ferry Corporation (BCFC). There was no directive to prohibit vehicles from being stopped on the apron during the final stages of loading operations. The TO's workload and responsibilities were considerable. Vehicular noise and the use of informal procedures and non-standard vocabulary effectively diminished the quality of communication. There was no procedure in place to double-check the clearances. The LRO did not check to ensure that the upper ramp apron was clear of the ship. The LRO lifted the lower apron without authority from the LDO. The ferry sailed prematurely and the upper ramp lost support, tipping the van and its occupants into the water. During the rescue operation, difficulty was experienced in launching and rowing a lifeboat with a minimum emergency response crew. 3.2 Causes Established clearance procedures were not followed and the ferry departed prematurely from the berth. Contributing to this occurrence were the shore and shipboard personnel's preoccupation with maintaining the ferry schedule and communication problems associated with the use of portable radios by terminal personnel. 4.0 Safety Action 4.1 Action Taken 4.1.1 Operational Review Following this occurrence, the British Columbia Ferry Corporation (BCFC) carried out an operational review of corporation procedures in conjunction with the Canadian Coast Guard (CCG) which resulted in recommendations being made to improve passenger and crew safety. 4.1.2 Commission of Inquiry Recommendations As a result of this occurrence, a Commission of Inquiry was established under former Chief Justice Nathan Nemetz. The Commission made 14 recommendations with a view to preventing recurrences. Subsequently, BCFC implemented all the recommendations. 4.1.3 Vehicle Loading Procedures In 1992, a TSB Marine Safety Advisory was forwarded to the CCG to ensure that the new loading procedures of BCFC do not result in the stoppage of vehicles on the ramp apron or in the area immediately behind it. Subsequently, BCFC has included instructions in its revised Ramp-specific Manual of Instructions to prohibit vehicles or pedestrians from stopping on an apron which links a vessel to a shore ramp. In addition, the CCG has made several recommendations concerning loading procedures and physical improvements at the Nanaimo and Horseshoe Bay terminals. In response, BCFC implemented the following procedures at the Nanaimo terminal: In addition to the upper and lower ramp operators, a ramp supervisor is now assigned to confirm to the lower deck officer (chief officer) the completion of loading and lifting clear of the upper and lower ramps from decks. Hard-wire telephone communication is now used between the ramp operators and the tower for the final confirmation of the end of loading and ramp clearance. The quartermaster and the second officer (two key loading personnel) now stay at their posts until the passenger and upper vehicle ramps have been raised and then report personally to the ferry master. At the Horseshoe Bay terminal, BCFC also provided a cargo net-style barrier and temporary ramp barriers to restrain foot passengers. 4.1.4 Sailing Schedule BCFC established a joint task force on scheduling and its impact on safety. The review process was completed in May 1993. Seven recommendations were made to mitigate the risks associated with the existing scheduling. These recommendations are now being implemented. 4.1.5 Safety Audit of Loading and Unloading Procedures A safety audit of the procedures relating to ramp closing and to shore and vessel clearances was carried out. Specific instructions have been established for deck loading officers, upper ramp operators, and second officers in performing vessel clearance duties. 4.1.6 Training for Ramp Operators BCFC has revised its ramp operation training procedures. Newly hired terminal attendants will be required to complete the Building Service Maintenance and Traffic Control training units before taking the Ramp Operation training. 4.1.7 Tower Operators - Workload and Training The workload of tower operators was reviewed and their duties are now limited to those directly related to traffic control, and loading and clearance procedures. Further, all 56 BCFC tower operators are now required to participate in the revised training program. 4.1.8 Radio Communication Training and Procedures BCFC has developed a Basic Radio Training Manual and has established standard protocols throughout all its terminals to improve the reliability and effectiveness of radio communication for terminal operators. 4.1.9 Video Camera Surveillance Video cameras, linked to colour monitors on the bridge, have been installed to enable the master of the QUEEN OF NEW WESTMINSTER to view simultaneously the bow and stern upper and lower decks and the passenger walkways. Similar video cameras have also been installed on all major BCFC ferries. 4.1.10 Ramp Apron Warning Lights A single lamp accessible only when ramp aprons are free and clear of the vessel and warning strobe lights installed at each passenger and vehicle access point to provide warning before vessel departure are now fitted on all major BCFC ferries. 4.1.11 Fast Rescue Boat (FRB) Rigid-hull inflatable fast rescue boats have been installed on major BCFC ferries, and training is being provided through boat drills.